What are Electronic Health Records?
Electronic health records (EHRs) are digital versions of paper charts that contain a patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images and laboratory test results. EHRs allow healthcare providers to access and update patient information easily and securely, helping improve the speed, quality, safety and cost of patient care.
Setting EHR Standards
In the early 2000s, healthcare organizations implemented EHRs independently with little coordination. This led to incompatible systems and data that couldn't be shared between providers. In response, the federal government created programs to accelerate EHR adoption and set technical standards. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 allotted billions in incentive payments for doctors to transition to digital records.
New regulations established by the Office of the National Coordinator for Health Information Technology resulted in much more interoperability between Electronic Health Records systems from different vendors. Standards were put in place for documentation, billing, prescriptions and other aspects of medical recordkeeping. This allowed previously incompatible systems to communicate and securely transfer health information electronically.
Benefits of EHR Usage
Access to complete patient histories has helped reduce medical errors, duplicate tests and unfounded drug interactions. EHRs store information in a centralized location that is accessible by multiple providers and staff members. This coordinated approach improves patient care coordination and lets doctors make more informed treatment decisions.
Studies have shown EHR use leads to better preventive care like cancer screenings and vaccinations. Built-in clinical decision support alerts healthcare teams about overdue tests or treatments based on a patient's age, gender and medical history. EHRs also facilitate remote care through telehealth and the sending of records electronically during referrals or hospital admissions.
Savings in paperwork and filing have reduced administrative costs for medical practices. Providers no longer have to maintain expensive storage of paper files or spend staff hours locating missing charts. Electronic billing and reimbursement has streamlined insurance claim processing as well.
Adapting to Change
While the transition to digital records brought benefits, it also presented new challenges. Doctors had to adjust to using computers during patient visits instead of paper charts. Early Electronic Health Records systems were often clunky with non-intuitive interfaces that disrupted clinical workflows.
Providers spent more time battling tech issues and data entry rather than interacting with patients. Reporting requirements from payers and regulators increased documentation burdens. Meaningful use criteria tied incentive payments to achieving specific EHR functions which some doctors felt were unrealistic or didn't necessarily improve care.
Healthcare organizations have responded by upgrading EHR software designs to be more user-friendly and mobile-enabled. Streamlined templates cut down on unnecessary clicks. Voice recognition and other innovative input methods reduce time spent typing notes. Interoperability and analytics features were expanded to maximize the technology's clinical value. Ongoing EHR optimization aims to make systems less obstructive so doctors can focus fully on patient care.
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